The Letter – Checklists are for…well, checking things

If we’re lucky, we learn our most important lessons from the mistakes of others. You’re socializing with off-going crews in your agency’s dayroom when someone reaches over your partner Bud’s shoulder.

“Here,” she says. “This was in yesterday’s mail.”

Bud notes the return address, and his conversation ceases mid-sentence. The room goes quiet as he slits the envelope and unfolds a one-page letter. He’s still reading it when your supervisor enters the room and invites both of you into an adjoining classroom. The expression on her face is serious. There’s a similar letter for you, and she hands it to you as you each take a seat.

The letter is from your agency’s attorney. Your agency has been named in a lawsuit as a result of a vehicle failure several months ago, and the attorney wants to meet with you both. Your ambulance ran out of fuel on the way to a cardiac arrest, and a patient subsequently died. The call came in an hour after shift change, while you and Bud were having coffee with another crew. Bud received a written warning at the time of the call for falsifying the unit’s fuel level on your morning checklist. Even then, he had a reputation for pencil-whipping his documentation.

You’ve been expecting this letter. But now, reading the terse legal language, you feel a distinct prickly sensation at the back of your neck. Lots of people are being blamed for this person’s wrongful death, including Bud, you, your supervisor, your education coordinator and your ops manager. But especially Bud. And you.

This was Bud’s fault, pure and simple. He was the driver that day. I checked the patient compartment and Bud checked the mechanical systems. We take turns; that’s how it works. Not only that, but very few people survive cardiac arrests. We both felt bad after this call, but we didn’t cause the cardiac arrest. I don’t think it’s fair. Why should we be blamed for the person’s outcome?

You sounded about right there for a moment, until you brought up the patient’s survivability. It wasn’t the patient’s duty to survive. It was your duty to help, and due to issues that were under your control, that didn’t happen. Now this thing is in the hands of attorneys, and you’ve left it to someone else to decide who’s culpable and who’s not. I think you’re in trouble.

How is it my fault? I checked my part of the ambulance. I always do.

I’m no attorney, but I think we’re all responsible for what we know. You’re a trained observer. When you realize your partner has checked the mechanical systems without opening the hood, you’re responsible for that information. When you sit down at a coffee shop 10 minutes after clocking in, you know what kind of checklist you’ve done. And when you sign the checklist and see that your partner has just drawn lines through the sections that pertain to the mechanical systems, you’re responsible for your own doubts, too. Let’s face it: You’ve trusted your luck for some time now. You know better than that.

What am I supposed to do? I’m not Bud’s supervisor. I have enough trouble doing my own job without being responsible for his too. Besides, Bud’s a nice guy. I’m sure as hell not going to run to a supervisor and rat on him every time he screws up. Who wants to work in that kind of environment?

You’re right, of course. On the other hand, your ambulance can either earn you a living or kill you, any day of your career. To be blunt, Bud is not your friend. He’s a slug. He cheats. He’s knowingly risked your life, your future, your family’s welfare, your agency’s financial resources, the good names of your colleagues and the lives of others rather than doing his job. And you’re enabling him to go right on doing it. If that doesn’t bother you, it should. And if it bothers you but you’re ignoring it, maybe you shouldn’t be surprised when somebody steps in and shakes you up some. Face it, that’s what attorneys do.

Like aircraft, ambulances consist of mechanical, electrical, hydraulic and structural systems. Every one of those systems is destined to fail eventually, and it’s your job to stay aware of yours every minute of every day.

See, your morning coffee is this whole other thing.

Thom Dick has been involved in EMS for 40 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of the EMS World editorial advisory board.